Provider First Line Business Practice Location Address:
323 S. MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANGELS CAMP
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95222
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-736-2507
Provider Business Practice Location Address Fax Number:
209-736-8367
Provider Enumeration Date:
04/20/2026